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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200446
Report Date: 06/28/2024
Date Signed: 06/28/2024 03:55:04 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/28/2024 03:55 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:BRIDGESFACILITY NUMBER:
019200446
ADMINISTRATOR/
DIRECTOR:
SOKODOLO, KOLU G.FACILITY TYPE:
735
ADDRESS:21259 BIRCH ROADTELEPHONE:
(510) 244-7153
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 4CENSUS: 0DATE:
06/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Ebony Omelagah/Licensee and
Lorenzo Pennix/Regional Director
TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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At 1:40 p.m. on this day, June 28, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. The facility appeared vacant. LPA called and spoke over the phone with Regional Director (RD) Lorenzo Pennix, and informed the reason for visit. RD and Ebony Omelagah, licensee, arrived at 2:30 p.m.

The facility underwent major repair as the result of fire back in 11/2022.

LPA toured the facility inside out with the RD and licensee. Repair appeared completed.

LPA verified, and licensee stated there's no major change in the physical plant lay out except the office is bigger than it was before and the closet of one of the bedrooms was changed to the opposite side of the bedroom.

Licensee to submit an updated sketch to LPA by July 12, 2024. In addition, licensee to check with the fire department if inspection is needed and inform LPA, so LPA can proceed to the next step if fire inspection is needed.

Licensee and RD stated that assessment of prospective resident has started.

Licensee and/or RD to submit the following documents before admission of first resident, and to notify LPA when first resident is admitted:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan

No deficiency cited. Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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